Hospice & Palliative Care of Chenango County Inc.

“Based on a review of 4 patient records with delayed or no admission, and interviews with the Executive Director, Director of Patient Programs, and Clinical Officer, it was determined the family of 1 patient (patient #4) expressed concerns/complaints to agency staff and the the Hospice failed to identify it as a complaint and complete a complaint investigation.Evidence as follows: Patient #4 was referred to the agency on 04/01/25 with a terminal diagnosis of gastrointestinal stromal tumor of the small intestine. The Hospice failed to investigate complaints made to the Hospice.The Hospice’s complaint policy reviewed 07/2024 included: - Complaints/concerns brought to the direct attention of any Hospice employee or volunteer are addressed immediately whenever possible and brought to the Director of Patient Family Services and or Executive Director. - All complaints are documented in a complaint log no more than 5 business days from the date the complaint was first received. - An Investigation is conducted by appropriate personnel of all written or verbal complaints received by the Hospice.The Hospice’s Admission Policy revised 07/2024, included: - Once admission is approved by the Medical Director, a phone call to arrange an initial interview with the patient and caregivers will be made by an RN/SW, or designee, within 48 hours of the referral whenever possible.On 04/01/25, the agency received a referral from the patient’s physician that included a recent history and physical, medication list, imaging reports and lab results; the referral also included “ASAP” (as soon as possible). Per date stamp the referral was faxed to the Hospice on 04/01/25 at 11:25 a.m. The patient’s record included documentation for the patient as follows: - skilled nursing to assess and evaluate; start date 04/01/25 - Medical Social Worker to assess and evaluate; start date 04/01/25 On 04/17/25 at 8:48 a.m., the Director of Patient Programs documented a late entry: - “04/03/25, Director of Patient Programs: records received 04/03/25, request to MD to review for appropriateness.” On 04/17/25 at 8:50 a.m., the Director of Patient Programs documented a late entry: “04/04/25, Director of Patient Programs, per Hospice MD, patient is appropriate for Hospice with dx (diagnosis) gastrointestinal stromal tumor of small intestine. Returned call to [spouse] left VM.” (voice message)On 04/09/25 at 4:24 p.m., the Director of Patient Programs documented a late entry: “04/06/25 writer called [spouse] to review the Hospice referral. Patient is appropriate for Hospice. Wife requests Tuesday 04/08/25 at 1 p.m. for admission to Hospice. DME (durable medical equipment) ordered for delivery Monday 04/07/25 as per patient caregiver request.”On 04/17/25 at 11:43 a.m., the surveyor interviewed the Director of Patient Programs who stated:- they had called the patient’s spouse on Friday the 4th and left a voicemail.- they were “admin on-call” Saturday, 04/05/25 and had received a call from the on-call RN who had reported the patient’s family was upset and had made a complaint when they learned the patient would not be admitted that day. The Director of Patient Programs stated that they called the family that afternoon.On 04/17/25 at 12:30 p.m., the surveyor interviewed Executive Director who stated on 04/05/25 they received a call from the Director of Patient Programs (on call administrator) who reported the on-call nurse had received a call from the family of a patient who had not yet been admitted requesting admission for their family member. The Executive Director said per the Director of Patient Programs the family was upset and the Executing Director requested the Director of Patient Programs call the family back. The surveyor requested the Executive Director provide the agency’s phone logs or electronic verification of when the Director of Patient Programs had phoned the patient. On 04/17/25 at 1:08 p.m., the Executive Director provided a screen shot of one phone call made to the patient on 04/07/25 at 11:11 a.m. and stated there were no more calls found. The surveyor interviewed the Executive Director and inquired what the process was for Hospice physician record review and approval of admission, and also sought clarification regarding whether the records were received on 04/01 or 04/03/25. The Executive Director explained the process, which included a “group chat” of agency personnel and scrolled back through the group chat to show the surveyor the screen dated 04/03/25 at 7:53 a.m. that read “[patient’s name] yes.” According to the Director, the Hospice physician had reviewed the records and approved of the patient for admission at that time.On 04/22/25, the surveyor conducted a follow-up interview with the Executive Director and determined the group chat included the entire “IDG” (interdisciplinary group) and “basically the whole organization.”On 04/17/25, at 1:38 p.m. the surveyor interviewed the patient’s spouse via phone. who stated: - they made a call to the Hospice on Thursday 4/3/25 since they hadn’t heard from the Hospice - the Hospice told them they had received the referral but were still waiting for the doctor’s progress notes - the Hospice told them they would get back to the later that afternoon (04/03) or Friday (04/04) - the first call they received from the Hospice was on Monday, 04/07/25 to schedule the admission visit for the following day, at 11:00 a.m.On 04/17/25, at 2:57 p.m. the surveyor interviewed a family member of the patient via phone who reported the same information as the spouse.Both the family member and spouse stated they were requesting admission as the patient was increasingly restless, anxious, confused, and in a significant amount of pain.The family member stated on 04/05/25, a call was placed to the Hospice, and they were patched through to the on-call registered nurse (RN). They requested the on-call nurse come out and admit the patient due to the rapid decline in the patient’s condition and inability of the spouse and family to manage the patient’s pain and restlessness. The family member stated the RN said, “that’s not how it works, you have to wait until Monday.” They then requested to speak to a supervisor and were told by the RN they could talk to them on Monday, and they told the RN they were upset and would be making a complaint. The spouse stated that during the call on 04/07/25 the Hospice staff: - said the patient couldn’t be admitted Monday because the admitting nurse had the day off - asked if they needed oxygen and/or a hospital bed. The spouse stated that they responded that they did need a hospital bed, but didn’t know if the patient needed oxygenThe spouse stated a hospital bed was delivered Monday. On 04/18/25 at 9:50 a.m., the surveyor interviewed the Clinical Officer who stated: - they were ill and out of work 04/04, 04/07, and 04/08/25 - they were “on triage call” over the weekend of 04/05 and 04/06/25 - the family member was upset when informed admission could not happen Saturday the 5th, and asked to speak to a supervisor - they informed the family member they couldn’t speak to anyone else until Monday and at that time, the family member became more upsetOn 04/08/25 at 7:28 a.m., the on-call RN documented: - 6:30 a.m., telephone call from family member stating patient passed at 5:55 a.m. Patient currently is not a Hospice patient. Writer advised to call 911 to pronounce the patients passing. Funeral home was also called and advised the same. - The patient’s spouse had some concerns about the process of admission and did not want to talk at this time. On 04/17/25 at 9:13 a.m., the surveyor had requested the Hospice Complaint Log since 01/01/25 and complaint policy. The Executive Director provided the Concerns/Grievances policy and 2 complaints. Neither complaint was from the family or spouse of patient #4.On 04/17/25 at 12:30 p.m., the Executive Director was asked why the complaint wasn’t in the complaint log. The Executive Director stated when they spoke to the Director of Patient Programs on Saturday the 5th, they didn’t consider it a complaint. The Executive Director was then asked if they had seen the notes written by the on-call nurse and they stated they had, but didn’t consider it a complaint because they didn’t consider them a patient.The Hospice failed to: - Identify the issues/concerns expressed by the patient’s family as a complaint. - Follow Hospice policy and immediately address the complaint brought to the attention of the Clinical Officer, Director of Patient Programs, Executive Director and the contracted on-call RN. - Investigate the complaint to determine whether there were any issues or systems problems resulting in. or as a result of, delayed admission.Failure to ensure that the agency investigates complaints and resolves issues has the potential for unmet patient needs.”

“Based on a review of medical records, staffing schedules, policies, and interviews with the Executive Director, Director of Patient Programs, and Clinical Officer, the Hospice failed to ensure patients routinely have access to nursing services 24 hours a day.Evidence as follows: Patient #4 was referred to the agency on 04/01/25 with a terminal diagnosis of gastrointestinal stromal tumor of the small intestine. The agency failed to admit the patient timely after the Hospice physician approved the patient. On 04/03/25, the Hospice received a call from the patient’s spouse requesting the patient be admitted to the Hospice due to the rapid decline of the patient which included increases in restless, anxiety, pain and the inability of the family to manage these symptoms.On 04/05/25 at 11:36 a.m., the patient’s family member called the Hospice and spoke to the on-call registered nurse (RN). They requested the patient be admitted for the reason above and when they learned the patient wouldn’t be admitted, informed the RN they wished to speak to “higher-up” to voice concern about the delay, and they would be making a complaint.On 04/17/25 at 9:10 a.m., the surveyor received the employee roster, and at 10:30 a.m. requested the registered nurse (RN) schedules for the period of 04/01-04/09/25.The employee roster included the following nurses: - Clinical officer RN, full time - Quality Assurance (QA) RN, from remote location - RN, part time - Licensed practical nurses, 2 full timeOn 04/17/25 at 11:43 a.m. the surveyor interviewed the Director of Patient Programs who stated admissions were not usually done on the weekend due to the difficulties getting “comfort packs and DME” (medications and equipment).A review of the RN schedule for 04/04/25 determined: - the part time RN was on duty 8:30 a.m.-2 p.m. - the Clinical Officer was on duty 8:30 a.m.-4:30 p.m. and on-call 4:30 p.m.-8:30 a.m. - the QA RN was on duty for “nursing triage” 8:30 a.m.-4:30 p.m.A review of the RN schedule for 04/05 and 04/06/25 determined: - the Clinical Officer was on-call 24 hours 8:30 a.m. 04/05 to 04/06/25 4 p.m. - an LPN was on call 4:30 p.m. 04/06 – 8:30 a.m. 04/07/25 - a contracted RN was on duty 4:30 p.m. 04/06 to 8:30 a.m. 04/07/25On 04/17/25 at 12:30 p.m. the surveyor interviewed the Executive Director and asked about RN coverage. The Executive Director stated: - they were short RNs but had hired a new RN that was to start soon after recovery from an injury - they had contracted with another Hospice to cover the “on-call” gaps - The Clinical Officer was on vacation this week (04/14-04/18/25)During the interview with the Executive Director, the surveyor asked why the patient hadn’t been admitted on Friday, Saturday, or Sunday. The Executive Director stated the RNs schedule was full on Friday, and they don’t usually admit on the weekends.On 04/18/25 at 9:10 a.m., the surveyor interviewed the on-call RN from 04/05/25 via phone who stated, “I was out sick on Friday the 4th, Monday the 7th, and Tuesday the 8th, but I took call over the weekend,” (April 5th and 6th).On 04/22/25 at 10:36 a.m., the surveyor conducted a follow-up phone interview with the Executive Director who stated: - the contracted on-call RN does not perform visits to patients - the QA on-call RN does not perform visits to patients The Hospice failed to ensure RN services were available: - between 2 p.m. 04/04/25 and 8:30 a.m. 04/07/25 - during the week the Clinical Officer was on vacation, 04/14-04/17/25 from 2 p.m.-8:30 a.m.Failure to ensure nursing services are available 24/7 may result in the Hospice’s inability to provide admission, and pain and symptom management, in a timely fashion; and may result in negative patient outcomes.”